The purpose of the health system is to serve and help improve the health of the population. The above quotes from our new Health Minister, Barbara Hogan, and from the recently released World Health Report, are apt introductions to this 2008 South African Health Review, which focuses on the revitalisation of Primary Health Care on the 30th anniversary of the Declaration of Alma Ata.

Alma Ata 30 years on : 'Health for all need not be a dream buried in the past". This quote, on the front page of a recent issue of The Lancet, is as pertinent to South Africa as it is internationally, and it is very apt that this year's South African Health Review is dedicated to the revitalisation of Primary Health Care.

This chapter provides a brief overview of the concept of Primary Health Care and how the Primary Health Care approach has been implemented in different international contexts. In this process, the key successes and failures of its implementation over the past 30 years, and specifically the emergence of large global health initiatives and their influence on Primary Health Care will be reflected upon. Finally, the current interest in revitalising Primary Health Care and what implications this has for South Africa will be considered.

Throughout much of the twentieth century, South Africa was a global leader in the conceptualisation and development of the Primary Health Care approach. Its seminal contributions include : the Pholela Health Centre model; the pioneering health system policies of the Gluckman Commission; development of the community-oriented primary care movement; the apartheid-era emigration of South Africa's leading community-oriented primary care proponents and subsequent dispersion and development of community-oriented primary care / Primary Health Care principles internationally; the development of the progressive Primary Health Care movement; and experimentation with new models of health service delivery and primary care. These achievements remained fragmented and of limited impact as a result of hostile state interventions and an egregious policy environment prior to and throughout the apartheid era. Despite over a decade of structural reform and genuine commitment to achieving 'Health for All', a series of obstacles continues to limit the full implementation of Primary Health Care today. These include : the HIV and AIDS pandemic; health worker shortages and inequities in resource distribution; shortcomings of political, public sector and medical / health leadership; and a complex and protracted health transition. While there is strong justification for a renewed commitment to, and major investment in Primary Health Care today, this effort must go beyond addressing these persisting challenges, and more broadly incorporate innovative health system designs and experimental work at scale, in order to reorient today's over-bureaucratised and often rigid primary care system.

The National Health Act is the key piece of legislation in the health sector, and thischapter focuses firstly on the extent to which this Act has been brought into effect over the past year. Other important pieces of health legislation are in the process of being brought into effect, including a new Nursing Act. In general, implementation of existing laws on the statute books has been slow, but some progress has been made with the less controversial aspects of the National Health Act. The second half of 2008 has been dominated by the tabling of a number of Amendment Bills relating to health, including a National Health Amendment Bill. These are expected to be taken through Parliament in 2008, despite the truncated terms provided as a result of the looming General Election in 2009. Court decisions can also have a dramatic impact on health legislation and on the development and implementation of policy. Some of these key recent cases are also covered in this chapter. Implementation-level policies continue to be developed, and a listing of recent key documents emanating from the national Department of Health is provided. Overall, the situation continues to be characterised by conflict, particularly between the Ministry / Department of Health and various stakeholders in the health sector. The potential gains that could stem from a more inclusive and participatory policy and legislative process remain elusive, but important.

Despite uncertainty about the exact levels of mortality, it is clear that the health of the South African population has worsened in the last decade. South Africa can be considered to have a quadruple burden of disease, including diseases and conditions related to poverty and under-development, chronic diseases, injuries and HIV and AIDS. The spread of HIV has been extremely rapid with an extensive impact, particularly among young adults and children. Differentials in health status have been observed between population groups, wealth groups, urban-rural and education levels. Globally, there has been a renewed interest in the determinants of health, including social determinants. A review of South African trends shows that economic and social policies have resulted in economic growth and some improvements in access to basic services such as water, sanitation and electricity. Increased provision of social grants, extreme wealth inequalities and high unemployment likely play an important role in poor health outcomes. Cultural and macro-social trends are difficult to capture, but of obvious concern to health are the culture of violence and the lower social status afforded to women. The theoretical understanding of health and its determinants is not completely formed. Nonetheless, the World Health Organization Commission on Social Determinants of Health argues that there is enough evidence for governments to take action following three principles: improving the daily living conditions of people; reducing health inequalities; and strengthening the ability to monitor population health. A revitalised Alma Ata provides an aspirational charter to build primary curative and preventive care accompanied by intersectoral action linking health and action.

This chapter will examine the current actions, including lifestyle measures, for the prevention and management of non-communicable diseases within a South African context. It will also focus on the biological, behavioural and social determinants of health. Interventions and initiatives directed at primary, secondary and tertiary prevention of chronic non-communicable diseases are also discussed. This chapter ends with recommended lifestyle changes, which can be taken to influence the adoption of healthy lifestyles, and therefore reduce the risks for chronic non-communicable diseases.

This chapter presents the progress and challenges in sexually transmitted infections, HIV and AIDS, and tuberculosis in South Africa. Issues such as the epidemiology and management of sexually transmitted infections are presented, as well as a number of interventions, which need to be carried out in order to address current problems. The new HIV & AIDS and STI National Strategic Plan for South Africa, 2007-2011, which is the national response to the epidemic is presented. The linkages between HIV and tuberculosis are discussed, as well as recommendations around the integration and collaboration between tuberculosis and HIV and AIDS activities. The chapter concludes with suggestions on implementing control programmes for these diseases, as well as ideas around strengthening effective interventions.

According to the Alma Ata Declaration, health is a fundamental human right. Post-1994, South Africa passed legislation that moved the country in the direction of Primary Health Care at the district level. This chapter reviews the challenges to community-wide access to mental heath services in South Africa. The background to mental health care in South Africa is first presented. The introduction of Primary Health Care in South Africa is discussed in relation to the Alma Ata Declaration and other international developments, such as selective Primary Health Care. The challenges regarding the integration of mental health care into the Primary Health Care system, namely poverty, the biomedical orientation of health care, staff workload and inadequate support, poor infrastructure, and limited funding and resources, are discussed, followed by an overview of the de-institutionalisation process. It is argued that integration within the framework of a biomedical model is insufficient. A holistic approach to integration, incorporating the social, economic, psychological and cultural aspects of illness, is necessary. The chapter concludes with recommendations for policy implementation, training and research.

Since the Alma Ata Declaration on Primary Health Care, South Africa has striven, in particular, to promote the health of women and children. As the world focuses on the Millennium Development Goals of 2015, achievements resulting from efforts in this area over the past 30 years are recognised, while lessons learned are identified where necessary. There have been several successes in maternal, child and women's health and nutrition, including: free access to Primary Health Care; free health care to pregnant and lactating women and to children under the age of six; prevention of vertical transmission of HIV; high immunisation coverage rate due to the Expanded Programme on Immunisation; eradication of deaths due to polio and measles; and implementation of the Choice on Termination of Pregnancy Act and the Primary School Nutrition Programme. Furthermore, diarrhoeal diseases have diminished, respiratory infections have become manageable and common foods have been fortified with micronutrients. On the other hand, challenges include a shortage of health care workers, poverty and HIV infection. Although efforts in these areas need to be increased, the impact of HIV has been of such a magnitude that it is unlikely that the Millennium Development Goals for maternal and child mortality will be met by 2015. Recommendations made in this chapter aim to increase efforts in maternal, newborn, child and women's health, and to address issues such as violence against women and children.

Malnutrition impacts negatively on morbidity, mortality, educability and productivity. Notwithstanding the success reported in relation to the reduction of specific nutrient deficiencies such as folate and iodine, the overall nutritional status of the South African population has not improved over the last fourteen years. In reality, the double burden of disease has become more severe with the increased prevalence of micronutrient deficiencies (i.e. vitamin A and iron) together with high levels of overweight and obesity. The Integrated Nutrition Programme is located within a Primary Health Care framework, is based on internationally accepted 'best practice' and has a comprehensive set of interventions. Analyses of selected interventions suggest that implementation is sub-optimal. Inadequate human resources and lack of appropriate capacity have been identified as critical contributors to the lack of progress. Improvement in the nutrition situation will therefore require a concerted and coordinated effort to develop a range of capacities at different levels and within different cadres of health workers. These capacities and skills should not only be developed in-service, but should also be infused during training. In addition, further research into implementation is encouraged to assist in finding sustainable solutions for South African nutrition problems.

The importance of environmental health services in Primary Health Care and health services in general, will be highlighted in this chapter. Outlined will be the developments in environmental health services since 1978, including the impact of various new pieces of legislation, such as the National Health Act. Challenges with the devolution of environmental health services to metropolitan and district municipalities are explored. An assessment of some of the main environmental health components such as water, sanitation, food and malaria is provided. Furthermore, the critical issue of human resources for environmental health will be discussed, and recommendations are made for stronger support to be provided for the delivery of environmental health services, especially by district municipalities.

This chapter reviews the progress made in recent years to strengthen human resources to deliver health care within a Primary Health Care approach. It focuses specifically on the availability and preparedness of old and new cadres of health workers, their distribution within the South African health system, as well as their training and development. Findings suggest that overall the health workforce is substantially weaker today than it was in the mid-1990s. There are fewer doctors and nurses available for the vast majority of public sector dependent population, as production has not kept up with population growth, increasing care needs and attrition. Disparities between provinces remain, and disparities between the private and public sectors have grown. The nursing sector faces a serious crisis brought on by an aging professional population. Progress with the development of mid-level cadres has been slow, with pharmacy being the exception. Furthermore, the implementation of community health worker programmes remains fragmented and uneven. Importantly, while there has been curriculum reform in many medical schools, there has been no fundamental shift in the orientation and resourcing of health professions. Health workers entering primary or community care services, thus, often remain ill-prepared and find themselves poorly supported and resourced. It is suggested that the following areas must be a priority in the human resource agenda in coming years : an accelerated production of professionals and mid-level cadres; comprehensive curriculum audits; the regulation and integration of community health workers; and an integrated and comprehensive reconfiguration of Primary Health Care teams.

This chapter examines trends in expenditure and funding of Primary Health Care services. It builds on previous models to develop an updated funding norm for Primary Health Care services in the public sector. Spending on public sector Primary Health Care services amounted to R297 per capita uninsured in 2006 / 07 and budgeted amounts rise to R395 per capita by 2010 / 11 (stated in 2007 / 08 prices). An updated funding norm is proposed of R401-R444 per capita (2007 / 08 prices) for visit rates ranging from 3 to 3.5 visits per person per year. The majority of districts are currently funded below the norm and progressive funding improvements are recommended. However, these also need to be linked to performance and efficiency. Inequities between districts are large with per capita annual expenditure ranging from R191 to R633. Nevertheless, the differences in per capita spending on Primary Health Care are gradually declining. These differing expenditure patterns point to the need for a better developed and more equitable approach to determining resource allocations to health districts.

This chapter reviews the role of information in decision making for Primary Health Care. The concepts inherent in a routine health information system, and the measures to supplement that data with population surveys and special studies are discussed. The importance of investing in human resources is also emphasised in this chapter. Issues such as the need to have adequate staff with appropriate skills to support the health information system are discussed, particularly because health information systems is a new field, which is poorly addressed by undergraduate training courses at present. The District Health Information System software and other information databases are described as the tools that support and inform the use of information for management and supervision at local and district levels. The information system is used for monitoring health services at facility level and is a powerful evaluation tool. Possible priority developments in the health information system are described. The chapter concludes with specific recommendations for strengthening health information systems in South Africa.

A review of health research conducted in South Africa between 1994 and 2007 will be presented in this chapter. The purpose of this review was to assess the extent to which health systems research has reflected the country's emphasis on Primary Health Care, and also the extent to which health research in general has reflected articulated national research priorities. The review revealed that the proportion of health systems research focusing on Primary Health Care issues has increased significantly since 1994. However, this research has focused primarily on quality of care and human resources for health, while aspects of Primary Health Care, like accessibility to, and equity of care have been relatively neglected. The number of publications in the area of HIV and AIDS has risen dramatically since 1994, and is an area which dominates all other disease-related research. Conclusions are drawn that research institutions, oversight bodies and researchers, should give more attention to those areas of Primary Health Care and health problems, which have been relatively neglected in the past 14 years in the South African research arena.

The private sector is playing an increasing role in the provision of Primary Health Care through both the for-profit and not-for-profit portions of the sector. In the post-1994 era, the relevance of this sector for the uninsured population has been markedly increased, due to corporate social investment and employee assistance programmes aimed at this population. A dramatic increase in donor-funded, health-related activities, in the HIV and AIDS and tuberculosis fields, has further expanded this sector's involvement in providing Primary Health Care services to a larger proportion of the population. However, this sector has a relative over concentration of skilled human resources, a situation that appears to be immune to all policy attempts to reverse it. Given this reality, serious consideration should be given to finding mechanisms to leverage these resources, so that they can provide services to the larger community. Government proposals, such as those for a social health insurance system, would help better align the population with health care providers and should therefore be encouraged and fast tracked. A mechanism needs to be developed that would allow the contracting of the private sector, including the not-for-profit component, to address current unmet health service delivery needs among the South African population. Not utilising this resource while the public sector annually shows unspent budget allocations for Primary Health Care services makes little sense.

This chapter presents a selection of the best available data on the functioning and performance of the South African health system. It also questions whether the data provide evidence of a system that is truly based on Primary Health Care principles. Accordingly, it draws attention to data on the social determinants of health, which received particular attention at Alma Ata and have been highlighted once again with the release of the World Health Organization's World Health Report this year.

The available evidence reflects enormous variability in the quality of information in the different health information systems as well as variability in the risk factors and determinants of health, health care delivery, as well as health outcomes.
Overall the information available suggests that while progress has been made with policy formulation and some inputs (e.g. financing) and processes (e.g. immunisation), inadequate provision and maldistribution of human resources linked with incomplete implementation of policies has resulted in ongoing inequities. Some outcome and impact indicators, measured in terms of morbidity and mortality, show either little improvement or even deterioration over time.
The implementation of both health care delivery and information systems do not accommodate the interdepartmental and interdisciplinary responses that are required to adequately address the social determinants of poor health and achieve comprehensive Primary Health Care. This challenge has to be faced in relation not only to infectious diseases, but also in relation to the increasing burden of chronic non-communicable diseases.
The sections for which data are included are given in the table of contents following.